MedMe x Telemed MD Travel Health Program Interest Form

Thank you for your interest in the MedMe x Travel MD Travel Health Program! Please fill out the interest form below, and we'll reach out shortly.

First Name*

Last Name*

Email*

Pharmacy Name*

Existing Customer*

I'm an existing MedMe Customer

I'm not an existing MedMe Customer

Additional Comments

Travel Certification*

As part of our travel program requirements, pharmacies must provide proof of travel training certification to proceed. Please upload a valid certificate below.

Please fill in and submit this Service Agreement in order to enroll in the Travel Health Program. Upload Signed Services Agreement Here:*